Code of silence prevails as young suffer

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Victorian coroners investigating the deaths of children in state care had not made one recommendation about Department of Human Services policies or practices over a two-year period, a study has found.

The study's authors say this is at odds with expectations - "that the coronial process would provide a mechanism through which a critique of protective practice could be brought to public attention".

Phillip Swain, head of the School of Social Work at Melbourne University, and research assistant Michelle Roberts examined 27 coronial findings in 1999 and 2000 involving children under protective orders or investigation by the Victorian Department of Human Services.

Such deaths are automatically investigated by the Coroner's office and are analysed by the Victorian Child Deaths Review Committee, which operates under the auspices of the department and which investigates the department's handling of cases.

The authors found the two investigators worked in isolation from one another. As well, "some matters investigated by DHS appear not to have been referred to the Coroner, and some investigated via the Coroner do not appear in DHS reports of its internal investigations, although the children concerned were known to the department".

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State Coroner Graeme Johnstone said recommendations on child protection had been made in the past, in cases not examined by the authors, and the focus of inquiries conducted by the Coroner's office and the child death review committee differed. "Nevertheless, I would be keen to explore ways of working with the Child Deaths Review Committee to identify problems at a far earlier stage," he said.

Coroner Phillip Byrne, in his recent finding on the death of Jed Britton, reported in The Sunday Age last week, says he found himself in a quandary after reading the Child Deaths Review Committee's report on the case.

He later discovered a long-standing protocol in which the committee's reports were provided on a "coroner's eyes only" basis, and could not be used in coronial findings or disclosed to the public. Had he known of the protocol, he would not have read the report because he believed all the material he had access to should be available to people with a legitimate interest.

A compromise was found after DHS produced a separate document identifying deficiencies in Jed's care. Mr Johnstone said the protocol process was "flawed" and in future DHS would produce separate statements for the coroner.

Mr Byrne's finding on Jed Britton, who was killed by his mother's de facto husband, was released five years after Jed's death. The authors of the new study, published in the Journal of Family Law, report cases taking more than three years.

They say long delays meant family members could not move on, and diminished the ability of the Coroner to influence DHS practices.